Citation Nr: 0000894 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 96-05 210 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased disability rating for service-connected post-traumatic headaches, currently evaluated as 30 percent disabling. 2. Entitlement to an increased disability rating for left wrist disorder, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Allen, Associate Counsel INTRODUCTION The veteran served on active duty from October 1990 to March 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1995 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Atlanta, Georgia, which denied a claim by the veteran seeking entitlement to an increased disability rating for headaches, rated as 10 percent disabling, and a left wrist condition, rated as 0 percent disabling. Subsequently, in a January 1996 decision, the RO granted an increased rating, to 10 percent, for the veteran's left wrist disorder. In a June 1996 decision, the RO granted an increased rating, to 30 percent, for the veteran's post-traumatic headaches. FINDINGS OF FACT 1. All evidence necessary for an equitable adjudication of the veteran's claim has been developed. 2. The medical evidence shows the veteran's headaches are daily and involve diffuse, throbbing pain of varying intensity. They improve with rest and do not involve nausea, vomiting, aura, speech difficulties, or other manifestations of migraine. 3. The medical evidence does not show very frequent completely prostrating and prolonged migraine headache attacks productive of severe economic inadaptability. 4. The veteran's left wrist disorder is currently manifested by tenosynovitis of the dorsal compartment, subjective complaints of pain on motion and tenderness over the first dorsal component with a full range of motion and intact grip strength. 5. Ankylosis of the left wrist is not shown by the medical evidence of record. Two or more major joints are not affected. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for the veteran's service-connected post-traumatic headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Codes 8045, 8100, 8205-8412 (1999). 2. The criteria for a disability rating in excess of 10 percent for the veteran's service-connected left wrist disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5024, 5214, 5215 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background Initially, the Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A well-grounded claim is one that is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Here, the veteran's claim is well grounded because he has established service connection for headaches and a left wrist disorder and has claimed that the disabilities have worsened since last rated; medical evidence has been submitted which the veteran's believes supports his contentions. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (where a veteran asserted that his condition had worsened since the last time his claim for an increased disability evaluation for a service-connected disorder had been considered by VA, he established a well-grounded claim for an increased rating). Because the veteran's claims are well-grounded, VA has a duty to assist with the development of the claims. 38 U.S.C.A. § 5107(a) (West 1991). In this regard, the Board notes that the RO obtained all medical evidence that the veteran indicated was available and provided the veteran with VA examinations of his disabilities. The veteran has not indicated that there is any other relevant evidence available but not yet of record. Overall, the Board finds that no further assistance is required to comply with the duty to assist, as mandated by 38 U.S.C.A. § 5107(a) (West 1991). Service-connected disabilities are rated pursuant to diagnostic codes (DC) in the Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1999) (Rating Schedule). It must be noted that the pyramiding of various diagnoses of the same disability is prohibited. 38 C.F.R. § 4.14 (1999). Where there is a question as to which of two evaluations under a specific diagnostic code shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). It is noteworthy that, in considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (1999); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the current level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Finally, in deciding claims for VA benefits, "when there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant." 38 U.S.C.A. § 5107(b) (West 1991). II. Increased rating for post-traumatic headaches a. Evidence Service medical records do not indicate that the veteran had headaches prior to enlistment, according to an October 1989 induction medical examination report and report of medical history. A February 1992 service emergency care record shows that the veteran was seen with neck pain after being struck on the head by a 75 pound barrel. A 1.5 centimeter laceration was noted on his head. Neurological examination was unremarkable. There was mild tenderness to palpation of the right lateral neck. X-rays of the cervical spine revealed no fracture. Assessment was muscle strain, right neck. A February 1992 service outpatient record shows that he was seen for headaches, occurring since being hit in the head with a barrel. The headaches were generalized with occasional white spots noted when standing up too fast. Physical examination of the neck revealed a superficial laceration, tenderness, and mild soft tissue swelling. Assessment was post-traumatic headaches. The veteran was placed on temporary light duty for 1 week due to the post- traumatic headaches. The veteran opted to separate from service without undergoing a separation medical examination. He separated from service, effective March 1992. An October 1992 VA examination report shows complaints of headaches on the right side of the head about once or twice per month, which lasted 2 or 3 days. Diagnosis was mild, post-concussion cephalalgia. Private outpatient records from April 1992 to August 1994 show that the veteran was seen for headaches on 4 occasions. An August 1994 outpatient clinic note indicates complaints of headaches. It notes that the veteran had a long-standing history of post-traumatic headaches. A September 1994 VA admission record shows that the veteran was hospitalized for 2 days due to headaches. Reported history was of headaches with sharp pain, but no visual difficulties, nausea, emesis, extremity weakness, or speech difficulties. General physical examination was unremarkable. Impression was history of chronic headaches, status post head injury. A September 1994 VA neurology consultation report indicates that the veteran had a fine tremor of the outstretched hands, right greater than left. There were no cerebellar or sensorimotor deficits. Palpation of vertex produced supraorbital radiating pain bilaterally. Palpation to occipital ridge produced periauricular radiating pain. Impression was musculoskeletal cephalalgia with probable element of greater occipital neuralgia, and secondary migraine headaches superimposed and possibly triggered by the musculoskeletal headaches. A September 1994 VA computed tomography (CT) study revealed a normal head. An October 1994 VA surgical report shows that the veteran underwent bilateral occipital nerve blocks. A November 1994 follow-up note indicates that the procedure did not alleviate his headaches. A November 1994 VA admission record shows that the veteran was hospitalized for 5 days due to headaches. Physical examination, including neurologic evaluation, was normal. An electrocardiogram (ECG) was normal. During hospitalization, the veteran was placed on prescription medication for his headaches, which he refused to take, indicating that they made him sleepy and weak. Diagnosis was chronic post- traumatic headaches. A May 1995 VA neurology consultation report indicates that the veteran's headaches numbered approximately 1 per day, progressive in severity. The more severe headaches involved throbbing and photophobia. Headaches occasionally woke the veteran at night. Impression was migraine and musculoskeletal headaches. A September 1995 VA neurology consultation report reiterates the veteran's headache history and complaints. A November 1995 VA examination report indicates complaints of daily headaches, lasting about 30 minutes to 3 or 4 hours. The veteran reported occasionally seeing white spots prior to onset of headache. There was no history of nausea. The headaches improved with rest. Diagnosis was post concussion headaches. VA outpatient records show that the veteran was seen for headaches on 3 occasions from March 1996 to December 1996. A February 1997 VA examination report indicates complaints of constant headaches that were diffuse and severe. The veteran indicated that he was unable to hold a job due to them. He had headaches every day, lasting all day, with variable intensity. He denied any visual symptoms, except for occasional black spots. There was no nausea, vomiting, or aura. Neurological examination of the cranial nerves was normal, as was sensory examination. Impression was that the veteran had a headache disorder consistent with a post- traumatic headache disorder. After review of the claims file, the physician remarked that the veteran's work-up was essentially normal for organic disease to explain his headaches. He probably also had tension headaches with a musculoskeletal component. b. Analysis The veteran's service-connected post-traumatic headaches were most recently rated pursuant to DC 8045-8100 of the Rating Schedule, indicating that they are caused by brain trauma and are rated by analogy to migraines. 38 C.F.R. § 4.124a, DC 8045, 8110 (1999). DC 8045 pertains to brain disease due to trauma. It states that a purely neurological brain trauma disability is to be rated according to the DC that specifically deals with such disability, and that purely subjective complaints, e.g. headache, recognized as symptomatic of brain trauma, will be rated 10 percent and no more under DC 9304, unless there is a diagnosis of multi- infarct dementia due to brain trauma. 38 C.F.R. § 4.142a, DC 8045, 9304 (1999). In this case, the medical evidence consistently shows that the veteran's service-connected headaches are "post- traumatic" in nature. In addition, they are manifested only by subjective complaints of constant pain, with occasional throbbing and observance of white or black spots. Objective evaluation has been consistently negative. Physical and neurological examinations have been entirely unremarkable. X-rays, ECG, and head CT have all been negative. As stated in the most recent 1997 VA examination report, medical treatment is negative for any organic disease to explain the headaches. In light of the lack of any objective manifestations, the Board finds that the most appropriate disability rating under DC 8045 is 10 percent. As stated above, and to the veteran's benefit, he has been rated as 30 percent disabled by analogy based on DC 8100. DC 8100 pertains to migraines and authorizes a 30 percent rating for migraines "[w]ith characteristic prostrating attacks occurring on average once a month over last several months." 38 C.F.R. § 4.124a, DC 8100 (1999). A maximum 50 percent rating is authorized when there is "very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability." Id. In this case, after careful review of the record, the Board concludes that the veteran's service-connected headaches warrant the current 30 percent rating under DC 8100. Specifically, it finds that his headaches are frequent. In 1992, he reported that they occurred once or twice per month. Beginning in 1994, he reported that they were daily. Medical records show that the veteran has been admitted and evaluated for his headaches on several occasions over the last few years. Overall, the Board finds that his headaches are "very frequent." See 38 C.F.R. § 4.124a, DC 8100 (1999). However, the headaches must also involve "completely prostrating and prolonged attacks" that are "productive of severe economic inadaptability" in order for an increased rating to be granted. Id. Here, the medical evidence does not indicate such a severity of symptoms. Mainly, his headaches consist of diffuse throbbing pain, of varying intensity. The veteran also intermittently reported seeing white or black spots prior to onset of the headaches. However, the medical evidence consistently shows that his headaches do not involve any nausea, vomiting, aura, speech difficulty, extremity weakness, or other manifestation of migraine. The headaches improved with rest. Overall, the Board concludes that the veteran's headaches do not have "very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability." Id. Therefore a disability rating in excess of 30 percent under DC 8100 is not warranted. It is noteworthy that the veteran's headaches are post- traumatic and, apparently, musculoskeletal in nature. A September 1994 VA admission report indicates that his head pain likely involved occipital neuralgia. Therefore, his disability could alternatively be rated under neuralgia of the cranial nerves. Neuralgia of the cranial nerves is to be rated based on paralysis of the affected nerve, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (1999). Paralysis of the cranial nerves is addressed in DC 8205-8412. 38 C.F.R. § 4.124a (1999). Under these DCs, moderate incomplete paralysis of any of the cranial nerves warrants a 10 percent disability rating. Id. Therefore, a rating in excess of 30 percent is not available under these codes. Overall, the Board finds that the veteran's headaches are of such severity as to warrant the current 30 percent rating under DC 8045-8100 of the Rating Schedule. A higher rating is not warranted. As a result, his claim must be denied. The evidence in regards to this issue is not so evenly balanced so as to allow application of the benefit of the doubt rule as required under the provisions of 38 U.S.C.A. § 5107(b.) III. Increased rating for left wrist disorder a. Evidence Service medical records note no left wrist problems upon the veteran's entry into active duty, according to an October 1989 induction medical examination report. The associated report of medical history indicates that the veteran was right-handed. A March 1991 service outpatient record reflects that the veteran had left wrist pain of 2 weeks duration. There was a history of tenosynovitis which had been injected with steroids prior to service. Physical examination revealed a tender left wrist over the distal radius. There was pain with side-to-side range of motion. The wrist was neurovascularly intact. Assessment was tenosynovitis, left wrist. The veteran was provided a wrist splint. He was placed on temporary limited duty for 2 weeks for a strained left wrist. Another March 1991 outpatient record indicates that his left wrist pain was persisting. X-rays were negative for fracture or dislocation. Assessment was tendonitis, left wrist. No further treatment for any left wrist problems in shown in the service medical records. Subsequent to service, an October 1992 VA examination report indicates that the veteran complained of left wrist soreness. He denied a history of any injury, sprain, or fracture. Physical examination revealed some slight tenderness with ulnar and radial deviation. Palmar flexion and dorsiflexion caused no difficulty. X-rays of the left wrist were negative. Diagnosis was history of tendonitis, left wrist. Private medical records from April 1992 to August 1994 show no complaints of or treatment for any left wrist problems. October 1994 and November 1994 VA outpatient notes indicate that the veteran complained of left wrist pain. A November 1994 VA medical care record indicates, as medical history, that the left wrist was status post-fracture 3 years prior. Objective examination revealed normal active range of motion of the hand and fingers. A December 1994 VA rehabilitation medicine record indicates that the veteran fractured his left wrist 3 years prior and had had pain since that time. X-rays were negative for fracture or dislocation. Carpal bones were intact. Hand grip was 120 pounds in right hand and 80 pounds in left hand. There was pain on the lateral side of the left wrist. There was no atrophy. Passive and active abduction of the wrist was painful. There was sensitivity to palpation. There was sensory impairment to pinprick of the left thumb. Impression was left wrist tendonitis secondary to old injury. A November 1995 VA examination report indicates that, according to medical history provided by the veteran, he injured his left wrist in service when a 75 to 80 pound drum fell on it. Current complaints were of pain on lifting heavy objects and limited motion. Examination revealed no swelling, deformity, subluxation, or instability of the left wrist. Range of motion was radial deviation to 20 degrees, ulnar deviation to 10 degrees, palmar flexion to 40 degrees, and dorsiflexion to 68 degrees. On the right, radial deviation was to 25 degrees, ulnar deviation to 42 degrees, palmar flexion to 75 degrees, and dorsiflexion to 70 degrees. X-rays were essentially negative. Diagnosis was residuals of trauma, left wrist. VA outpatient notes from October 1995, March 1996, and December 1996 indicate that the veteran had left wrist pain. A February 1997 VA examination report reflects that the veteran injured his left wrist when a drum hit it. Current complaints were of pain. Physical examination revealed a full range of motion of the left wrist and hand. There was tenderness over the first dorsal component with a positive Finkelstein's test. There was intact motor function with good grip component and intrinsic function. There was palpable radial pulse. There was no tenderness about the dorsal wrist. There was no tenderness of the left arm and no instability on motion. X-rays showed no obvious bony abnormality. Impression was left de'Quervains first dorsal tenosynovitis. It was remarked that the veteran's complaints were consistent with first dorsal compartment tenosynovitis, which was aggravated by his injury in service. b. Analysis The veteran's left wrist disorder is currently rated under Diagnostic Code (DC) 5024-5215 of the Rating Schedule, indicating that it involves tenosynovitis and is rated based on limitation of motion of the wrist. See 38 C.F.R. § 4.71a, DC 5024, 5215 (1999). Initially, the Board finds that rating the veteran's disability under these DCs is appropriate, given that the most recent medical evidence indicates that his disability involves tenosynovitis and that DC 5024 specifically pertains to tenosynovitis. See 38 C.F.R. §§ 4.20, 4.27 (1999) (In determining the proper rating for the veteran's service-connected disability, the Board must use the DC in the Rating Schedule that most closely resembles the condition, both in terms of the functions affected and anatomical localization, as well as symptomatology.). DC 5024 addresses tenosynovitis and authorizes a disability rating based on limitation of motion of the parts affected, as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5024 (1999). Degenerative arthritis is addressed in DC 5003. It states that degenerative arthritis is to be rated based on limitation of motion of the part affected. 38 C.F.R. § 4.71a, DC 5003 (1999). When limitation of the part affected is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, DC 5003 authorizes a 10 percent rating with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent rating when such involvement includes occasional incapacitating exacerbations. Id. Limitation of motion of the wrist is addressed in DC 5215. It authorizes a maximum 10 percent disability rating for limitation of wrist motion resembling dorsiflexion of less than 15 degrees or palmar flexion limited in line with forearm. 38 C.F.R. § 4.71a, DC 5215 (1999). Regulations provide that, in every instance where the Rating Schedule does not provide for a 0 percent (noncompensable) disability rating for a diagnostic code, such a rating shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1999). In this case, the most recent medical evidence shows that the veteran's left wrist has normal range of motion, according to the 1997 VA examination report. Less recently, in November 1995, the wrist was reported to have radial deviation to 20 degrees, ulnar deviation to 10 degrees, palmar flexion to 40 degrees, and dorsiflexion to 68 degrees. These medical documents do not indicate that the veteran's limitation of range of motion approaches dorsiflexion of less than 15 degrees, nor of palmar flexion in line with the forearm. In fact, none of the medical evidence of record indicates such a severity of limitation of range of motion. Objectively, the veteran's left wrist disability does not meet the criteria for a 10 percent disability rating under DC 5215. However, for musculoskeletal disabilities, the United States Court of Appeals for Veterans Claims (formerly Court of Veterans Appeals) held that 38 C.F.R. §§ 4.40, 4.45, were not subsumed into the diagnostic codes under which a veteran's disabilities are rated, and that the Board has to consider the "functional loss" of a musculoskeletal disability under 38 C.F.R. § 4.40, separate from any consideration of the veteran's disability under the diagnostic codes. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). In this case, the veteran's disability appears to be predominantly functional in nature. While he most recently had full range of motion, pain on motion has been consistently noted in the medical evidence. Of course, this pain is usually reported as a subjective complaint by the veteran. As such, his credibility must be ascertained. See Justus v. Principi, 3 Vet. App. 510 (1991). Here, the Board has some doubts as to the veteran's credibility. This doubt arises from inaccurate medical history provided by the veteran to his medical care providers. Specifically, the Board finds that the veteran recently informed his treating physicians that he "fractured" his left wrist during service, and that it was "injured" during service when a 75 pound drum hit it. However, a review of service medical records shows that the veteran's left wrist was only treated on one occasion (in March 1991) and that his only medical history was of tenosynovitis that existed prior to service. At that time, X-rays were negative for any fracture. While service medical records do show that the veteran was injured by a heavy drum during service, that injury involved his right forearm, not his left wrist. After service, during the veteran's first VA examination in October 1992, he reported no history of any left wrist injury, sprain, or fracture. However, beginning on or about November 1994, he consistently reported that he fractured his left wrist and that the injury was caused by a drum that fell on it. To date, X-rays have consistently shown no fracture of the left wrist. Overall, the Board has reason to doubt the veteran's statements, including those as to pain on motion of the wrist. Nevertheless, the Board cannot conclusively state that the veteran has no pain on motion of the left wrist. As such, it accepts that the veteran has some functional impairment caused by his service-connected left wrist disability. His pain on motion causes some functional limitation of motion. The Board finds no other functional impairment. The evidence shows that his wrist has no swelling, deformity, instability, atrophy, or other functional impairment. In light of the above, the Board finds that a 10 percent rating for limitation of motion of the wrist is warranted. 38 C.F.R. § 4.71a, DC 5215 (1999). Because the maximum rating under DC 5215 is 10 percent, the veteran is not entitled to a higher rating under that code. The Board must look to other DCs in the Rating Schedule to determine if a rating in excess of 10 percent is warranted. See 38 C.F.R. §§ 4.1, 4.2, 4.13 (1999). After review of the regulations, the Board finds no DC in the Rating Schedule that authorizes a disability rating in excess of 10 percent for the veteran's left wrist disorder. While DC 5214 allows for a higher disability evaluation, it pertains to ankylosis of the wrist. 38 C.F.R. § 4.71a, DC 5214 (1999). The veteran does not have ankylosis. Similarly, while DC 5003 authorizes a 20 percent rating when 2 or more joints are affected, the veteran's disability only involves 1 major joint, his left wrist. 38 C.F.R. § 4.71a, DC 5003 (1999). Overall, after careful review of the entire record, the Board finds that the veteran's left wrist disorder most closely reflects a 10 percent rating, based on functional impairment, and that a higher rating is not warranted under the Rating Schedule. As a result, his claim for an increased disability rating is denied. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. 4.71a, DCs 5003, 5024, 5214, 5215 (1999). The evidence in regards to this issue is not so evenly balanced so as to allow application of the benefit of the doubt rule as required under the provisions of 38 U.S.C.A. § 5107(b.) IV. Conclusion Application of the extraschedular provisions is also not warranted in this case. 38 C.F.R. § 3.321(b) (1999). There is no objective evidence that the service- connected disabilities at issue presents such an exceptional or unusual disability picture, with such factors as marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. Hence, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under the above-cited regulation, was not required. See Bagwell v. Brown, 9 Vet. App. 337 (1996). In this regard, while the veteran maintains that he is unable to work because of persistent headaches, as previously indicated, there is no objective evidence of very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. ORDER An increased disability rating for service-connected post- traumatic headaches is denied. An increased disability rating for service-connected left wrist disorder is denied. A. BRYANT Member, Board of Veterans' Appeals